Hospital Bed and Accessories - Adopted from the National Government Services website. For any item to be covered by The Health Plan, it must
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HOSPITAL BED AND ACCESSORIES
Hospital Bed and Accessories
Adopted from the National Government Services website.
For any item to be covered by The Health Plan, it must:
1. Be eligible for a defined Medicare or The Health Plan benefit category
2. Be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve
the functioning of a malformed body member
3. Meet all other applicable Medicare and/or The Health Plan statutory and regulatory
requirements
For the items addressed in this medical policy, the criteria for "reasonable and necessary" are defined by
the following indications and limitations of coverage and/or medical necessity. Please refer to individual
product lines certificates of coverage for possible exclusions of benefit.
For an item to be covered by The Health Plan, the supplier must receive a written, signed, and dated
order before a claim is submitted to The Health Plan. If the supplier bills for an item addressed in this
policy without first receiving the completed order, the item will be denied as not reasonable and
necessary.
Suppliers are to follow The Health Plan requirements for precertification as applicable.
Hospital beds require precertification and a physician face-to-face.
CMS Publication 100-3 Medicare National Coverage
CMS National Coverage Policy Determination Manual, Chapter 1, Sections 280.1,
280.7
DME Region LCD Covers Jurisdiction B
For services performed on or after 10/01/13
Review/Revisions Effective Date
Reviewed/Revised: 06/04/2018, 02/01/16
Plans will follow Coverage Determination posted on
the CGS website unless otherwise indicated in
The Health Plan sections of this policy, contractual agreements, or
benefit plan documents.
DESCRIPTION
A hospital bed is a single bed with a frame in three sections, so the head, middle, or foot can be raised
as required.
COVERAGE GUIDELINES
A fixed height hospital bed (E0250, E0251, E0290, E0291, and E0328) is covered if one or more of the
following criteria (1-4) are met:
1. There is a medical condition, which requires positioning of the body in ways not feasible with an
ordinary bed. Elevation of the head/upper body less than 30° does not usually require the use of
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a hospital bed, or
2. There is a medical condition that requires positioning of the body in ways not feasible with an
ordinary bed in order to alleviate pain, or
1HOSPITAL BED AND ACCESSORIES
3. There is a medical condition that requires the head of the bed to be elevated more than 30°
most of the time due to CHF, COPD, or problems with aspiration. Pillows or wedges must have
been considered and ruled out,
4. Traction equipment which can only be attached to a hospital bed is required.
A variable height hospital bed (E0255, E0256, E0292, and E0293) is covered when one of the criteria for
a fixed-height hospital bed is met and there is a requirement for a bed height different from a fixed-
height hospital bed to permit transfers to chair, wheelchair, or standing position.
A semi-electric hospital bed (E0260, E0261, E0294, E0295, and E0329) is covered if one of the criteria for
a fixed-height bed is met and there is a requirement for frequent changes in body position and/or there
is an immediate need for a change in body position.
A heavy-duty, extra wide hospital bed (E0301, E0303) is covered if one of the criteria for a fixed-height
hospital bed is met and the member’s weight is more than 350 lbs, but does not exceed 600 lbs.
An extra heavy-duty hospital bed (E0302, E0304) is covered if the member meets one of the criteria for
a hospital bed and the member’s weight exceeds 600 lbs.
Coverage Guidelines Accessories:
Trapeze equipment (E0910, E0940) is covered if the device is required to sit up because of a respiratory
condition, to change body position for other medical reasons, or to get in or out of bed.
Heavy-duty trapeze equipment (E0911, E0912) is covered if the criteria is met for regular trapeze
equipment and the member weigh’s more than 250 lbs.
A bed cradle (E0280) is covered when it is necessary to prevent contact with the bed coverings.
Side rails (E0305, E0310) or safety enclosures (E0316) are covered when they are required by the
member’s condition and they are an integral part of, or an accessory to, a covered hospital bed.
Replacement of an innerspring mattress (E0271) or foam rubber mattress (E0272) is covered if there is a
condition that requires replacement, for example – reasonable useful lifetime has been met, and the
member owns the hospital bed.
NONCOVERAGE STATEMENT
For any of the above hospital beds (plus those coded E1399 - see coding guidelines), if documentation
does not support the medical necessity of the type of bed billed, payment will be denied as not
reasonable and necessary. If the member does not meet any of the coverage criteria for any type of
hospital bed, or accessory it will be denied as not reasonable and necessary.
A total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height adjustment
feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary.
A bed board (E0273, E0315) is not covered since it is not primarily medical in nature.
An over bed table (E0274, E0315) is not covered because it is not primarily medical in nature.
Trapeze bars attached to a bed (E0910, E0911) are not covered when used on an ordinary bed.
REPLACEMENT AND REPAIR
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Replacements and repairs require precertification. See Replacement and Repair policy.
Repairs are not separately payable during the capped rental period.
2HOSPITAL BED AND ACCESSORIES
A replacement is not usually covered within the 5 year reasonable useful lifetime and for normal wear
and tear.
Will need documentation of change in medical condition and face to face for replacements within the 5
year reasonable useful lifetime.
Replacements are not covered due to neglect or misuse.
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3HOSPITAL BED AND ACCESSORIES
CODING INFORMATION
CPT/HCPCS codes: The appearance of a code in this section does not necessarily indicate coverage.
HCPCS MODIFIERS
NO PHYSICIAN OR OTHER LICENSED HEALTH CARE PROVIDER ORDER FOR THIS ITEM OR
EY
SERVICE
WAIVER OF LIABILITY STATEMENT ON FILE, ISSUED AS REQUIRED BY PAYOR POLICY,
GA
INDIVIDUAL CASE
GK REASONABLE AND NECESSARY ITEM/SERVICE ASSOCIATED WITH A GA OR GZ MODIFIER
MEDICALLY UNNECESSARY UPGRADE PROVIDED INSTEAD OF NON-UPGRADED ITEM, NO
GL
CHARGE, NO ABN
GZ ITEM OR SERVICE EXPECTED TO BE DENIED AS NOT REASONABLE AND NECESSARY
KX REQUIREMENTS SPECIFIED IN THE MEDICAL POLICY HAVE BEEN MET
HCPCS CODES
FIXED HEIGHT BEDS
E0250 HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITH MATTRESS
E0251 HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS
E0290 HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITH MATTRESS
E0291 HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITHOUT MATTRESS
HOSPITAL BED, PEDIATRIC, MANUAL, 360 DEGREE SIDE ENCLOSURES, TOP OF
E0328 HEADBOARD, FOOTBOARD AND SIDE RAILS UP TO 24 INCHES ABOVE THE SPRING,
INCLUDES MATTRESS
HCPCS CODES
VARIABLE HEIGHT BEDS
E0255 HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITH MATTRESS
HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITHOUT
E0256
MATTRESS
E0292 HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, WITH MATTRESS
E0293 HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, WITHOUT MATTRESS
HCPCS CODES
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SEMI-ELECTRIC BEDS
4HOSPITAL BED AND ACCESSORIES
HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE
E0260
RAILS, WITH MATTRESS
HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE
E0261
RAILS, WITHOUT MATTRESS
HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITHOUT SIDE RAILS,
E0294
WITH MATTRESS
HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITHOUT SIDE RAILS,
E0295
WITHOUT MATTRESS
HOSPITAL BED, PEDIATRIC, ELECTRIC OR SEMI-ELECTRIC, 360 DEGREE SIDE ENCLOSURES,
E0329 TOP OF HEADBOARD, FOOTBOARD AND SIDE RAILS UP TO 24 INCHES ABOVE THE
SPRING, INCLUDES MATTRESS
HCPCS CODES
TOTAL ELECTRIC BEDS
HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH ANY
E0265
TYPE SIDE RAILS, WITH MATTRESS
HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH ANY
E0266
TYPE SIDE RAILS, WITHOUT MATTRESS
HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS). WITHOUT
E0296
SIDE RAILS, WITH MATTRESS
HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITHOUT
E0297
SIDE RAILS, WITHOUT MATTRESS
HCPCS CODES
HEAVY-DUTY BEDS
HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN
E0301 350 POUNDS, BUT LESS THAN OR EQUAL TO 600 POUNDS, WITH ANY TYPE SIDE RAILS,
WITHOUT MATTRESS
HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER
E0302
THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS
HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN
E0303 350 POUNDS, BUT LESS THAN OR EQUAL TO 600 POUNDS, WITH ANY TYPE SIDE RAILS,
WITH MATTRESS
HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER
E0304
THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITH MATTRESS
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5HOSPITAL BED AND ACCESSORIES
HCPCS CODES
ACCESSORIES
E0271 MATTRESS, INNERSPRING
E0272 MATTRESS, FOAM RUBBER
E0273 BED BOARD
E0274 OVER-BED TABLE
E0280 BED CRADLE, ANY TYPE
E0305 BED SIDE RAILS, HALF LENGTH
E0310 BED SIDE RAILS, FULL LENGTH
E0315 BED ACCESSORY: BOARD, TABLE, OR SUPPORT DEVICE, ANY TYPE
E0316 SAFETY ENCLOSURE FRAME/CANOPY FOR USE WITH HOSPITAL BED, ANY TYPE
E0910 TRAPEZE BARS, A/K/A PATIENT HELPER, ATTACHED TO BED, WITH GRAB BAR
TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250
E0911
POUNDS, ATTACHED TO BED, WITH GRAB BAR
TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250
E0912
POUNDS, FREE STANDING, COMPLETE WITH GRAB BAR
E0940 TRAPEZE BAR, FREE STANDING, COMPLETE WITH GRAB BAR
HCPCS CODES
MISCELLANEOUS
E1399 DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS.
There are no specified diagnoses or ICD-10 codes that indicate medical necessity.
DOCUMENTATION REQUIREMENTS
Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there
has been furnished such information as may be necessary in order to determine the amounts due such
provider." It is expected that the medical record will reflect the need for the care provided. It is
generally understood that the medical record includes the physician's office records, hospital records,
nursing home records, home health agency records, records from other health care professionals and
test reports.
This documentation must be available with precertification.
Medicare has made changes to its requirements for dispensing orders, detailed written orders, and
proof of delivery. The Health Plan will require the following:
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1. Physician detailed written order. Order must include the following:
a. Member’s name
6HOSPITAL BED AND ACCESSORIES
b. Date
c. Description of item. The medical record must contain the information that supports the
request for each item and must be submitted with the precertification, if the item
requires precertification, or with the claim, if no precertification was required
d. Order must include diagnosis code
e. Physician signature with date. Date stamps are not appropriate
f. Quantity of items required and duration. A new order is required if there is an increase
in the quantity of the supply used per month and/or the type of supply used
The supplier is to contact The Health Plan in this instance to update referral
2. There must be documentation in the supplier’s records to support the medical necessity of that
item. This information must be available upon request, usually with precertification per The
Health Plan policy.
3. Proof of delivery to be kept on file by the provider of the item.
Note: If templates or forms are submitted, (i.e., a Medicare Certificate of Medical Necessity,
and/or a provider created form), The Health Plan reserves the right to request the medical
record, that may include, but not limited to, the physician office notes, hospital and nursing
facility records, and home health records.
Note: Template provider forms, prescriptions, and attestation letters are not considered part of
the medical record, even if signed by the ordering physician.
Precertification is required when supplies used are greater than the usual maximum quantity listed in
above. There must be adequate, clear documentation in the medical record corroborating the medical
necessity of this amount. This documentation is to be submitted with precertification.
HOSPITAL BED PROVIDED WHILE MEMBER IN COVERED PART A FACILITY
A hospital bed is usually included in the per diem rate of the facility and therefore not separately
billable. Facilities are to refer to their individual contracts.
EQUIPMENT RETAINED FROM A PRIOR PAYOR:
The Health Plan will not pay in excess of the contracted purchase price for any item in this policy. If the
provider is seeking payment from The Health Plan, the item must be precerted and The Health Plan will
pay the remaining rental months up to purchase price- if member meets guidelines above.
BILLING GUIDELINES
A Column II code is either included in the allowance for the corresponding Column I code when provided
at the same time or is considered a like/similar item and must not be billed separately at the time of
billing the Column I code.
Column I Column II
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E0250 E0184, E0186, E0187, E0196, E0271, E0272, E0277 E0305, E0310, E0373
E0251 E0305, E0310
7HOSPITAL BED AND ACCESSORIES
E0255 E0184, E0186, E0187, E0196, E0271, E0272, E0277 E0305, E0310, E0373
E0256 E0305, E0310
E0260 E0184, E0186, E0187, E0196, E0271, E0272, E0277 E0305, E0310, E0373
E0261 E0305, E0310
E0265 E0184, E0186, E0187, E0196, E0271, E0272, E0277 E0305, E0310, E0373
E0266 E0305, E0310
E0290 E0184, E0186, E0187, E0196, E0271, E0272, E0277 E0305, E0310, E0373
E0292 E0184, E0186, E0187, E0196, E0271, E0272, E0277 E0305, E0310, E0373
E0294 E0184, E0186, E0187, E0196, E0271, E0272, E0277 E0305, E0310, E0373
E0296 E0184, E0186, E0187, E0196, E0271, E0272, E0277 E0305, E0310, E0373
E0301 E0305, E0310
E0302 E0305, E0310
E0303 E0184, E0186, E0187, E0196, E0271, E0272, E0277 E0305, E0310, E0373
E0304 E0184, E0186, E0187, E0196, E0271, E0272, E0277 E0305, E0310, E0373
E0328 E0184, E0186, E0187, E0196, E0271, E0272, E0277 E0305, E0310, E0373
E0329 E0184, E0186, E0187, E0196, E0271, E0272, E0277 E0305, E0310, E0373
When mattress or bedside rails are provided at the same time as a hospital bed, use the single code that
combines these items.
E0271, E0272: Mattress, innerspring/foam rubber
When combined with E0251, bill as E0250
When combined with E0291, bill as E0290
When combined with E0293, bill as E0292
When combined with E0295, bill as E0294
When combined with E0266, bill as E0265
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When combined with E0297, bill as E0296
When combined with E0301, bill as E0303
8HOSPITAL BED AND ACCESSORIES
When combined with E0302, bill as E0304
E0305, E0310: Bedside rails, half-length/full-length
When combined with E0290, bill as E0250
When combined with E0291, bill as E0251
When combined with E0292, bill as E0255
When combined with E0293, bill as E0256
When combined with E0294, bill as E0260
When combined with E0295, bill as E0261
When combined with E0296, bill as E0265
When combined with E0297, bill as E0266
E0271, E0272: Mattress, innerspring/foam rubber plus
E0305, E0310: Bedside rails, half-length/full-length
When combined with E0291, bill as E0250
When combined with E0293, bill as E0255
When combined with E0295, bill as E0260
When combined with E0297, bill as E0265
Providers are to be aware of the billing guidelines for reimbursement for like and similar items in
regards to the American National Standards Institute for hospital beds with mattresses when the
member is currently renting or owns a medically necessary group I or II support mattress. See Pressure
Support Surfaces Group I and II policies.
Provider may bill a hospital bed without a mattress E0251, E0256, E0261, E0266, etc… and a group I or II
support surface indicated in the pressure support surfaces policy.
KX, GA, and GZ MODIFIERS
Suppliers may submit a claim with a KX modifier only if all the criteria for that item is met.
If coverage criteria are not met, the GA or GZ modifier must be used. When there is an expectation of a
medical denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly
executed Advance Beneficiary Notice (ABN) or the GZ modifier, if they have not obtained a valid ABN.
ADVANCED BENEFICIARY NOTICE
The Health Plan expects providers to follow the Medicare policy on ABN across all Medicare, Medicaid,
and Commercial plans.
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NOTE: Providers may be held financially responsible if they furnish the above items without notifying
the member, verbally and in writing, that the specific service being provided is not covered. This must be
done prior to the dispensing of the device. The provider must submit the waiver or ABN to The Health
9HOSPITAL BED AND ACCESSORIES
Plan with the claim showing the member agreed to pay for the device. Generalized statements on
waivers or ABN are not acceptable.
PRICING, DATA ANALYSIS, AND CODING (PDAC)
The Health Plan has implemented use of Medicare’s PDAC contractor for review of authorizations.
Suppliers should contact the PDAC contractor for guidance on the correct coding of these
items. dmepdac.com/
MEDICARE DEFINITIONS AND DESCRIPTION
A fixed height hospital bed is one with manual head and leg elevation adjustments, but no height
adjustment.
A variable height hospital bed is one with manual height adjustment and has manual head and leg
elevation adjustments.
A semi-electric bed is one with manual height adjustment and has electric head and leg elevation
adjustments.
A total electric bed is one with electric height adjustment and has electric head and leg elevation
adjustments.
An ordinary bed is one, which is typically sold as furniture. It may consist of a frame, box spring, and
mattress. It is a fixed height and may or may not have head or leg elevation adjustments.
E0301 and E0303 are hospital beds that are capable of supporting a member who weighs more than 350
lbs, but no more than 600 lbs.
E0302 and E0304 are hospital beds that are capable of supporting a member who weighs more than 600
lbs.
E0316 is a safety enclosure used to prevent a member from leaving the bed.
E1399 should be used for products not described by the specific HCPCS codes above.
AMA CPT/ADA CDT COPYRIGHT STATEMENT
CPT only copyright 2002-2017 American Medical Association. All Rights Reserved. CPT is a registered
trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee
schedules, relative value units, conversion factors and/or related components are not assigned by the
AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or
indirectly practice medicine or dispense medical services. The AMA assumes no liability for data
contained or not contained herein.
INTERNET LINKS AND SOURCES
National Government Services Local Coverage Determination Policy. Hospital Beds and Accessories. LCD
L27216 and Article A47240. Last accessed 06/04/2018. Retrieved
from apps.ngsmedicare.com/applications/lcd.aspx?CatID=3&RegID=51
CGS a Celerian Company. Hospital Beds and Accessories. LCD L33820 and Article A52508. Last accessed
06/30/2018. Retrieved from: cgsmedicare.com
12/6/2016
10HOSPITAL BED AND ACCESSORIES
West Virginia Medicaid Internet Provider Manual. Chapter 506. Covered Services, Limitations, and
Exclusions for DME Medical Supplies. Last accessed 06/04/2018. Retrieved
from dhhr.wv.gov/bms/Pages/default.aspx
The Pricing, Data Analysis, and Coding Contractor. Noridian. Internet website. Last accessed
06/04/2018Retrieved from https://www.dmepdac.com/dmecsapp/
Noridian Healthcare Solutions. Durable Medical Equipment. Supplier Manual, Chapter 3. Documentation
Requirements. Last accessed 06/04/2018. Retrieved
from noridianmedicare.com/dme/news/manual/chapter3.html
The Health Plan Provider Procedural Manual. Payment Voucher, Section 14, Page 11
12/6/2016
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